Comparison of Inpatient Standard-of-Care to Outpatient Oritavancin Therapy for Patients With Acute Uncomplicated Cellulitis.

BACKGROUND: Shifting inpatient antibiotic treatment to outpatient parenteral antimicrobial therapy may minimize treatment for acute bacterial skin and skin structure infections, including cellulitis. The purpose of this evaluation was to compare 30-day hospital readmission or admission due to cellulitis and economic outcomes of inpatient standard-of-care (SoC) management of acute uncomplicated cellulitis to outpatient oritavancin therapy. METHODS: This retrospective, observational cohort study was conducted at a 941-bed community teaching hospital. Adult patients 18 years and older treated for acute uncomplicated cellulitis between February 2015 to December 2018 were eligible for inclusion. Information was obtained from hospital and billing department records. Patients were assigned to either inpatient SoC or outpatient oritavancin cohorts for comparison. RESULTS: 1,549 patients were included in the study (1,348 in the inpatient SoC cohort and 201 in the outpatient oritavancin cohort). The average length of stay for patients admitted was 3.6 ± 1.5 days. The primary outcome of 30-day hospital readmission or admission due to cellulitis occurred in 49/1348 (3.6%) patients in the inpatient SoC cohort versus 1/201 (0.5%) in the outpatient oritavancin cohort (p = 0.02). The difference between costs and reimbursement was improved in the outpatient oritavancin group (p < 0.001). CONCLUSION: Outpatient oritavancin for acute uncomplicated cellulitis was associated with reduction in 30-day hospital readmissions or admissions compared to inpatient SoC. Beneficial economic outcomes for the outpatient oritavancin cohort were observed. Additional studies are required to confirm these findings.

Outpatient parenteral antibiotic therapy (OPAT) and inpatient treatment strategies for emergency department patients with cellulitis: a cost analysis.

OBJECTIVES: Emergency department (ED) patients with cellulitis requiring intravenous antibiotics may be treated via outpatient parenteral antibiotic therapy (OPAT) as opposed to hospitalization. The primary objective was to compare healthcare costs for the following strategies: community intravenous antibiotics with referral to an OPAT clinic operated by infectious disease specialists ('OPAT clinic' strategy); community intravenous antibiotics with return to ED if necessary ('return to ED' strategy); and hospital admission. METHODS: Using a hospital administrative database, we conducted a cost analysis using patient-level data of adult cellulitis patients presenting to two tertiary care EDs and were treated with intravenous antibiotics in one of three ways: OPAT clinic strategy; return to ED strategy; and hospital admission. Costs were estimated from Canada's publicly funded health system perspective. The primary outcome was the mean total cost (2015 CAD) per patient for each treatment strategy. A generalized linear model was performed to adjust for baseline characteristics, including age, sex and comorbidities. RESULTS: A total of 808 patients met inclusion criteria: OPAT clinic strategy (N = 341); return to ED strategy (N = 228) and hospital admission (N = 239). The mean total cost of care for the treatment strategies were: OPAT clinic: $2170 (95% CI $1905-$2436); return to ED: $1493 (95 %CI $1264-$1722); and hospital admission: $10,145 (95% CI $8668-$11,622). Results from the regression analysis suggested that the OPAT clinic strategy was associated with a cost-saving of $7394 (95% CI $6154-$8633, p < 0.001) compared to hospital admission and an increased cost of $651 (95% CI $367-$935, p < 0.001) when compared to the return to ED approach. CONCLUSIONS: This is the first Canadian study that compares the cost of different OPAT strategies for cellulitis patients. While both OPAT strategies are safe and far less costly than hospital admission, our findings suggest that a dedicated OPAT clinic for patients with cellulitis is more expensive than the return to ED strategy.

RéSUMé: OBJECTIFS: Les patients des services d'urgence atteints de cellulite nécessitant des antibiotiques intraveineux peuvent être traités par une antibiothérapie parentérale ambulatoire (OPAT) plutôt que par une hospitalisation. L'objectif principal était de comparer les coûts des soins de santé pour les stratégies suivantes : antibiotiques intraveineux communautaires avec orientation vers une clinique OPAT gérée par des spécialistes des maladies infectieuses (stratégie "clinique OPAT") ; antibiotiques intraveineux communautaires avec retour aux urgences si nécessaire (stratégie de "retour aux urgences") ; et admission à l'hôpital. MéTHODES: À l'aide d'une base de données administratives hospitalières, nous avons effectué une analyse des coûts en utilisant les données relatives aux patients adultes atteints de cellulite se présentant à deux urgences de soins tertiaires et traités par antibiotiques intraveineux de l'une des trois manières suivantes : Stratégie de la clinique OPAT ; stratégie de retour aux urgences; et admission à l'hôpital. Les coûts ont été estimés du point de vue du système de santé public du Canada. Le principal résultat était le coût total moyen (2015 CAD) par patient pour chaque stratégie de traitement. Un modèle linéaire généralisé a été réalisé pour ajuster les caractéristiques de base, y compris l'âge, le sexe et les comorbidités. RéSULTATS : Au total, 808 patients répondaient aux critères d'inclusion : stratégie clinique OPAT (N = 341) ; stratégie de retour aux urgences (N = 228) et admission à l'hôpital (N = 239). Le coût total moyen des soins pour les stratégies de traitement était le suivant : Clinique OPAT: 2 170 $ (IC 95 %: 1 905 $­2 436 $) ; retour aux urgences : 1 493 $ (IC à 95 %: 1 264 $­1 722 $) ; et hospitalisation : 10 145 $ (IC à 95 %: 8 668 $­11 622 $). Les résultats de l'analyse de régression suggèrent que la stratégie de la clinique OPAT est associée à une économie de 7 394 $ (IC à 95 %: 6 154 $­8 633 $, p < 0,001) par rapport à l'admission à l'hôpital et à une augmentation des coûts de 651 $ (IC à 95 %: 367 $­935 $, p < 0,001) par rapport à l'approche du retour aux urgences. CONCLUSIONS : Il s'agit de la première étude canadienne qui compare le coût de différentes stratégies d'OPAT pour les patients atteints de cellulite. Si les deux stratégies OPAT sont sûres et bien moins coûteuses que l'admission à l'hôpital, nos résultats suggèrent qu'une clinique OPAT dédiée aux patients atteints de cellulite est plus coûteuse que la stratégie de retour aux urgences.

Bacterial dacryoadenitis: clinical features, microbiology, and management of 45 cases, with a recent uptick in incidence.

PURPOSE: To review the clinical features, microbiology, management, and incidence of bacterial dacryoadenitis at our institution. METHODS: This was a case series examining patients with bacterial dacryoadenitis from 2004 to 2020. Charts were reviewed for demographics, comorbidities, presenting symptoms and signs, radiology, microbiology, and management. Main outcomes included need for surgical intervention or inpatient admission. RESULTS: Forty-five patients with bacterial dacryoadenitis had a mean age of 46.1 years. Presenting symptoms included eyelid edema (100%), extraocular motility restriction (53.3%), and purulent discharge (75.5%). Based on computed tomography or magnetic resonance imaging, 9 (20.5%) patients presented with definite abscess and 15 (34%) presented with a phlegmon or early abscess. Eleven patients (24.4%) required surgical drainage. Twenty patients (44.4%) required admission, for an average stay of 4 days (range 2-8 days). Common organisms included Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. Presence of an early abscess or phlegmon correlated with need for drainage (p < 0.01). Extraocular motility restriction correlated with need for drainage (p = 0.02) and admission (p = 0.05). The incidence of bacterial dacryoadenitis at our institution increased as a percentage of confirmed dacryoadenitis cases; from 2004 to 2010 the incidence was 0 to 9.1% per year, while from 2010 to 2019 the incidence ranged from 7.7 to 36.2%. In 2019, our institution had 17 cases (incidence 36.2%) of bacterial dacryoadenitis. CONCLUSIONS: Bacterial dacryoadenitis is a major cause of dacryoadenitis, and its incidence may be increasing. It can resolve with minimal complications if managed appropriately, although some patients may require surgical drainage or admission for intravenous antibiotics.

Cellulitis: A Review of Pathogenesis, Diagnosis, and Management.

Cellulitis is a common skin infection resulting in increasing hospitalizations and health care costs. There is no gold standard diagnostic test, making cellulitis a potentially challenging condition to distinguish from other mimickers. Physical examination typically demonstrates poorly demarcated unilateral erythema with warmth and tenderness. Thorough history and clinical examination can narrow the differential diagnosis of cellulitis and minimize unnecessary hospitalization. Antibiotic selection is determined by patient history and risk factors, severity of clinical presentation, and the most likely microbial culprit.

Improved economic and clinical outcomes with oritavancin versus a comparator group for treatment of acute bacterial skin and skin structure infections in a community hospital.

BACKGROUND: Oritavancin is a lipoglycopeptide antibiotic with in vitro bactericidal activity against gram-positive pathogens indicated for use in adults with acute bacterial skin and skin structure infections (ABSSSI). Its concentration-dependent activity and prolonged half-life provide a convenient single-dose alternative to multi-dose daily therapies for ABSSSI. This retrospective cohort study was conducted to quantify the clinical and economic advantages of using oritavancin compared to other antibiotic agents that have been historically effective for ABSSSI. METHODS: Seventy-nine patients received oritavancin who had failed previous outpatient antibiotic therapy (OPAT) for cellulitis or abscess and were subsequently readmitted to the hospital as an inpatient between 2016 and 2018. These patients were compared to a cohort of 28 patients receiving other antibiotics following OPAT failure and subsequent hospitalization for these two infection types. The primary clinical end point was average length of stay (aLOS) and secondary endpoints included readmission rates for the same indication at 30 and 90 days after discharge and the average hospital cost (aHC). RESULTS: A total of 107 patients were hospitalized for treatment of cellulitis or abscess. Demographic characteristics of both the oritavancin and comparator groups were similar except for the presence of diabetes. The primary clinical endpoint showed a non-significant decrease in aLOS between the oritavancin group versus comparator (2.12 days versus 2.59 days; p = 0.097). The secondary endpoints revealed lower readmission rates associated with oritavancin treatment at 30 and 90 days; the average hospital cost was 5.9% lower for patients that received oritavancin. CONCLUSION: The results of this study demonstrate that oritavancin provides not only a single-dose alternative to multi-day therapies for skin and skin structure infections, but also a clinical and economic advantage compared to other antibiotic agents.

Emergency department medication dispensing reduces return visits and admissions.

OBJECTIVES: Return visits to the emergency department (ED) and subsequent readmissions are common for patients who are unable to fill their prescriptions. We sought to determine if dispensing medications to patients in an ED was a cost-effective way to decrease return ED visits and hospital admissions for skin and soft tissue infections (SSTIs). METHODS: A retrospective review of ED visits for SSTIs, during the 24 weeks before and after the implementation of a medication dispensing program, was conducted. Charts were analyzed for both ED return visits and hospital admissions within 7 days and 30 days of the initial ED visit. Return visits were further reviewed to determine if the clinical conditions on subsequent visits were related to the initial ED presentation. A cost analysis comparing the cost of treatment to cost savings for return visits was also performed. RESULTS: Before the implementation of the medication dispensing program, the return rate in 7 days for the same condition was 9.1% and the rate of admission was 2.8%. The return rate for the same condition in 8-30 days was 2.1% and the rate of admission was 1.0%. After the implementation of the medication dispensing program, the return rate for the same condition in 7 days was 8.0%, and the admission rate was 1.7%. The return rate for the same condition in 8-30 days was 0.8%, and the admission rate was 0%. The total cost of dispensed medications was $4050, while total cost savings were estimated to be $95,477. CONCLUSION: A medication dispensing program in the ED led to a reduction in return visits and admissions for SSTIs at both 7 days and 30 days. For a cost of only $4050, an estimated total of $95,477 was saved. A medication dispensing program is a cost-effective way to reduce return visits to the ED and subsequent admissions for certain conditions.

Clinical features, microbiological epidemiology and recommendations for management of cellulitis in extremity lymphedema.

BACKGROUND: This high volume, single center study investigated the prevalence, bacterial epidemiology, and responsiveness to antibiotic therapy of cellulitis in extremity lymphedema. METHODS: From 2003 to 2018, cellulitis events from a cohort of 420 patients with extremity lymphedema were reviewed. Demographics, lymphedema grading, symptoms, inflammatory markers, cultures and antibiotic therapy regimens were compiled from cellulitis episodes data. Univariate and multivariate analyses were performed for detailed analysis. RESULTS: A total of 131 separate episodes of cellulitis were recorded from 43 (81.1%) lower limb and 10 (19.9%) upper limb lymphedema patients. The prevalence and recurrence rates for cellulitis in lymphedema patients were 12.6% (53 of 420) and 56.6% (30 of 53), respectively. The most common findings were increased limb circumference (127 of 131; 96.9%) and abnormal C-reactive protein (CRP) level (86 of 113; 76.1%). Blood cultures were obtained in 79 (60.3%) incidents, with 9 (11.4%) returning positive. Streptococcus agalactiae was the most isolated bacterium (5 of 9; 55.5%). CONCLUSIONS: The cellulitis prevalence and recurrence rate in extremity lymphedema were 12.6%, and 56.6%, respectively. Strongest indicators of cellulitis were increased affected limb circumference and elevated CRP level. Empiric antibiotic therapy began with coverage for Steptococcus species before broadening to anti-Methicillin-resistant Staphylococcus aureus and anti-Gram negatives if needed for effective treatment of extremity lymphedema cellulitis.

Intravenous ceftriaxone at home versus intravenous flucloxacillin in hospital for children with cellulitis: a cost-effectiveness analysis.

BACKGROUND: Outpatient parenteral antibiotic therapy after hospital admission is increasingly popular, but its use to avoid admission to hospital altogether by treating patients wholly as outpatients remains uncommon in children. One reason for the low use of treatment at home is the scarcity of evidence of its cost-effectiveness. In this planned follow-up analysis of the Cellulitis at Home or Inpatient in Children from the Emergency Department (CHOICE) trial, we aimed to assess the cost-effectiveness of an admission avoidance pathway, in which children were treated at home, compared with standard hospital care for the intravenous treatment of moderate or severe cellulitis. METHODS: We did a cost-effectiveness analysis to compare home treatment with intravenous ceftriaxone versus hospital treatment with intravenous flucloxacillin in children aged 6 months to 18 years who had presented to the emergency department at The Royal Children's Hospital, Melbourne, VIC, Australia, with moderate or severe uncomplicated cellulitis. We included costs from two sources: institutional costs at a patient level and expenses incurred by families. We measured effectiveness with quality-adjusted life years (QALYs), which we derived from the Child Health Utility 9D questionnaire, and a clinical outcome of treatment failure, which was the primary outcome of the CHOICE trial. We planned to calculate the incremental cost-effectiveness ratio, defined as the difference between groups in total cost divided by the difference between groups in effectiveness. The CHOICE trial is registered at ClinicalTrials.gov, number NCT02334124. FINDINGS: We included 180 children who comprised the per-protocol population in the CHOICE trial: 89 children in the home group and 91 children in the hospital group. The institutional cost per patient per episode was significantly lower in the home group than in the hospital group (AUS$1965 vs $3775; p<0·0001). The mean cost incurred per family was $182 for the home group and $593 for the hospital group (p<0·0001). Both measures of effectiveness were significantly better in the home group than in the hospital group: QALYs were 0·005 for the home group versus 0·004 for the hospital group (p<0·0001), and treatment failure occurred in one (1%) patient in the home group versus seven (8%) patients in the hospital group (risk difference -6·5%, 95% CI -12·4 to -0·7; p=0·029). Calculating the incremental cost-effectiveness ratio was thus deemed redundant. INTERPRETATION: Treatment at home was less costly and more effective than standard hospital care for children with moderate or severe cellulitis. These findings support development of this admission avoidance pathway in hospitals. FUNDING: The Royal Children's Hospital Foundation, Murdoch Children's Research Institute.

The Penicillin for the Emergency Department Outpatient treatment of CELLulitis (PEDOCELL) trial: update to the study protocol and detailed statistical analysis plan (SAP).

BACKGROUND: Cellulitis is a painful, potentially serious, infectious process of the dermal and subdermal tissues and represents a significant disease burden. The statistical analysis plan (SAP) for the Penicillin for the Emergency Department Outpatient treatment of CELLulitis (PEDOCELL) trial is described here. The PEDOCELL trial is a multicentre, randomised, parallel-arm, double-blinded, non-inferiority clinical trial comparing the efficacy of flucloxacillin (monotherapy) with combination flucloxacillin/phenoxymethylpenicillin (dual therapy) for the outpatient treatment of cellulitis in the emergency department (ED) setting. To prevent outcome reporting bias, selective reporting and data-driven results, the a priori-defined, detailed SAP is presented here. METHODS/DESIGN: Patients will be randomised to either orally administered flucloxacillin 500 mg four times daily and placebo or orally administered 500 mg of flucloxacillin four times daily and phenoxymethylpenicillin 500 mg four times daily. The trial consists of a 7-day intervention period and a 2-week follow-up period. Study measurements will be taken at four specific time points: at patient enrolment, day 2-3 after enrolment and commencing treatment (early clinical response (ECR) visit), day 8-10 after enrolment (end-of-treatment (EOT) visit) and day 14-21 after enrolment (test-of-cure (TOC) visit). The primary outcome measure is investigator-determined clinical response measured at the TOC visit. The secondary outcomes are as follows: lesion size at ECR, clinical treatment failure at each follow-up visit, adherence and persistence of trial patients with orally administered antibiotic therapy at EOT, health-related quality of life (HRQoL) and pharmacoeconomic assessments. The plan for the presentation and comparison of baseline characteristics and outcomes is described in this paper. DISCUSSION: This trial aims to establish the non-inferiority of orally administered flucloxacillin monotherapy with orally administered flucloxacillin/phenoxymethylpenicillin dual therapy for the ED-directed outpatient treatment of cellulitis. In doing so, this trial will bridge a knowledge gap in this understudied and common condition and will be relevant to clinicians across several different disciplines. The SAP for the PEDOCELL trial was developed a priori in order to minimise analysis bias. TRIAL REGISTRATION: EU Clinical Trials Register (EudraCT number: 2016-001528-69). Registered on 5 April 2016. ClinicalTrials.gov, ID: NCT02922686 . Registered on 9 August 2016.

Clinical Factors Associated with Readmission among Patients with Lower Limb Cellulitis.

BACKGROUND: There is substantial allocation of resources directed towards evaluation and management of lower limb cellulitis (LLC) in the acute care setting. Readmission for LLC is poorly understood, and there is little evidence with which to identify patients at risk for readmission. OBJECTIVE: To describe demographics, comorbidities, admission vital signs, and laboratory markers of infection among patients with LLC who are readmitted, and to investigate which among these factors is associated with readmission. METHODS: A cross-sectional retrospective cohort study was performed at tertiary and community hospitals within a regional health care system in order to summarize readmission characteristics. Univariate and multivariate models were created to estimate the likelihood of independent variables being associated with LLC readmission. RESULTS: The readmission rate was 11.2% with a median age of 68.6 years for the cohort. Increased age and subsidized insurance were associated with more frequent admissions. For every 10-year age increase, cellulitis subjects had a 14% increase in readmission odds (OR 1.14, CI 1.07-1.20). Patients with subsidized insurance had an almost twofold increased risk (OR 1.88, CI 1.42-2.50). Smoking, obesity, hypertension, diabetes mellitus, renal insufficiency, tachycardia, hypotension, leukocytosis, and neutrophilia were not more frequent in readmitted patients. CONCLUSIONS: Older age and subsidized insurance were associated with readmission whereas severity indicators for infection including abnormal vital signs and laboratory markers were not significantly associated. Factors other than severity of infection, such as socioeconomic factors, may influence clinical decisions related to readmission for LLC.

Assessing pharmacists' readiness to prescribe oral antibiotics for limited infections using a case-vignette technique.

Background Pharmacist's skills are underutilized whilst they are directly involved with antibiotic supply to the community. Addressing this issue could lead to better use of antibiotics and hence decreased resistance. Objective Explore how pharmacists can prescribe oral antibiotics to treat a limited range of infections whilst focusing on their confidence and appropriateness of prescribing. Setting Community pharmacies, Western Australia. Method Data were collected using a self-administered questionnaire also containing case vignettes. These were distributed to a random sample of metropolitan and rural community pharmacies in Western Australia. A Generalised Estimating Equation was used to compare respondents' level of confidence in treating various infections and to assess appropriateness of prescribing. Main outcome measure Appropriateness and confidence of antibiotic prescribing. Results A response rate of 34.2% (i.e. 425 responses to case vignettes) was achieved from 240 pharmacies. There were high levels of confidence to treat simple infections such as uncomplicated UTIs (n = 73; 89.0%), impetigo (n = 65; 79.3%), mild bacterial skin infections (n = 62; 75.6%) and moderate acne (n = 61; 72.4%). Over 80% of respondents were confident to prescribe amoxicillin (n = 73; 89%), trimethoprim (n = 72; 87.8%), amoxicillin and clavulanic acid (n = 70; 85.4%), flucloxacillin (n = 70; 85.4%) and cephalexin (n = 68; 82.9%). High levels of appropriate antibiotic prescribing were shown for uncomplicated UTI (97.2%), cellulitis (98.2%) and adolescent acne (100.0%). Conclusion This study identified key limited infections and antibiotics for which pharmacists were supportive and confident to prescribe. This role could lead to better use of antibiotics in the community and minimisation of resistance.

Who Can Have Parenteral Antibiotics at Home?: A Prospective Observational Study in Children with Moderate/Severe Cellulitis.

BACKGROUND: The benefits of treating children at home or in an ambulatory setting have been well documented. We aimed to describe the characteristics and evaluate the outcomes of children with moderate/severe cellulitis treated at home with intravenous (IV) ceftriaxone via direct referral from the Emergency Department to a hospital-in-the-home (HITH) program. METHODS: Patients aged 3 months to 18 years with moderate/severe cellulitis referred from a tertiary pediatric Emergency Department to HITH from September 2012 to January 2014 were prospectively identified. Data collection included demographics, clinical features, microbiological characteristics and outcomes. To ensure home treatment did not result in inferior outcomes, these patients were retrospectively compared with patients who were hospitalized for IV flucloxacillin, the standard-of-care over the same period. The primary outcome was home treatment failure necessitating hospital admission. Secondary outcomes included antibiotic changes, complications, length of stay and cost. RESULTS: Forty-one (28%) patients were treated on HITH and 103 (72%) were hospitalized. Compared with hospitalized patients, HITH patients were older (P < 0.01) and less likely to have periorbital cellulitis (P = 0.01) or fever (P = 0.04). There were no treatment failures under HITH care. The rate of antibiotic changes was similar in both groups (5% vs. 7%, P = 0.67), as was IV antibiotic duration (2.3 vs. 2.5 days, P = 0.23). CONCLUSION: Older children with moderate/severe limb cellulitis without systemic symptoms can be treated at home. To ascertain if this practice can be applied more widely, a comparative prospective, ideally randomized, study is needed.

False economies in home-based parenteral antibiotic treatment: a health-economic case study of management of lower-limb cellulitis in Australia.

OBJECTIVES: The majority of healthcare costs accrued managing cellulitis can be attributed to the small proportion of patients treated with parenteral antibiotics. Hospital in the home (HITH) instead of or following initial inpatient treatment is a safe and effective alternative, but there are few data evaluating its cost-effectiveness for cellulitis. PATIENTS AND METHODS: Our retrospective cohort study included all treatment episodes (by either HITH or an inpatient service for >24 h) with an ICD-10 primary diagnosis code of lower-leg cellulitis at a tertiary-level health service in Melbourne, Australia over 12 months (2012-13). Data included demography, social factors and ICD-10 codes mapped to major comorbidities constituting the Charlson comorbidity index (CCI). Differences in length of stay (LOS) and individual clinical costing (ICC) between HITH- and non-HITH-treated patients were tested with univariable and multivariable (generalized linear model) analyses. RESULTS: For 328 admissions in 294 patients, the average per-day costs were AU$431 for HITH and AU$761 for inpatient care. For 124 patients (38%) treated in HITH, both LOS [mean (95% CI) 7.48 days (6.76-8.20 days) versus 5.82 days (3.45-8.18 days)] and ICC [mean (95% CI) AU$5873 (AU$5212-AU$6534) versus AU$5196 (AU$4567- AU$5824)] were higher than those for patients with solely inpatient care. In multivariable analysis controlling for age, comorbidity, carer support and language, HITH remained associated with significantly longer LOS [1.63-fold (95% CI: 1.24- to 2.13-fold): P < 0.001] and non-significantly with higher cost [1.14-fold (95% CI: 0.97- to 1.34-fold): P = 0.11]. CONCLUSIONS: Management of cellulitis represents a substantial cost burden for hospital services. Modest per-day cost savings from HITH can be offset by much longer HITH LOS.

The costs of interdigital phlegmon in four loose-housed Finnish dairy herds.

BACKGROUND: The aim of the study was to provide detailed herd level cost information about an outbreak of interdigital phlegmon (IP), which has been an emerging problem with enlarged loose house barns in Finland in recent years. During enlargement, the farmer's financial situation is sensitive because of the large investments to the farm business and unexpected costs can risk the farm's survival. RESULTS: The University of Helsinki research herd and three commercial herds having outbreaks of IP in 2012 or 2013 were visited to collect detailed information about the costs and economic impact of the outbreaks. The majority of the costs came from the discarded milk due to the antibiotic treatments. In Finland IP is usually treated with parental benzylpenicillin for 5 days which result in discarded milk for a total of 11 days. Third generation cephalosporins, widely used in other countries, have no milk withdrawal time. However, the use of these antibiotics is not recommended in Finland since these antimicrobials are critically important for human health. Herd-level costs varied between 4560 and 28,386 € depending on the herd size, the frequency of the infected cows, the antibiotics used and other costs involved. The average cost per infected cow was 489 €. CONCLUSIONS: The outbreaks of IP cause severe economic losses to dairy farms and the costs are lower if cows are treated with antibiotics with no withdrawal time. However, other costs, such as involuntary culling, reduced production and fertility also produce substantial costs to the farms. Early detection of sick animals, rapid treatment and control measures to limit the outbreak of IP can lower the costs. Because of the high costs farms should concentrate on preventing the disease.

Outcomes After Skin and Soft Tissue Infection in Infants 90 Days Old or Younger.

BACKGROUND AND OBJECTIVES: Skin and soft tissue infections (SSTIs) are an increasingly common cause of pediatric hospital visits among infants. The optimal evaluation strategy for younger infants with SSTI is unknown because there is little information about outcomes including risks of concomitant bacterial infections and treatment failure. This study was designed to determine rates of concomitant invasive bacterial infection and hospital revisits for treatment failure as well as factors associated with treatment failure in infants presenting with SSTI. METHODS: Retrospective study of patients≤90 days of age who received care from the 22 emergency departments and hospitals in the Intermountain Healthcare system from July 1, 2004 to December 31, 2011, with a primary discharge diagnosis of SSTI. Concomitant bacterial infections were defined as urinary tract infection (UTI; culture-confirmed) or invasive bacterial infection (IBI; culture-confirmed bacteremia and/or meningitis). Treatment failure was defined as any unplanned change in care at hospital revisit within 14 days of discharge. RESULTS: The study included 172 infants; 29 (17%) were febrile, and 91 (53%) had ≥1 sterile site culture performed. One case of bacteremia in a febrile infant was identified giving an overall proportion with UTI/IBI of 0.58% (95% confidence interval 0.01%-3.2%). Sixteen infants (9.3%; 95% confidence interval 5.4%-14.7%) returned for treatment failure. Perianal location (P=.03) and private insurance status (P=.01) were associated with more treatment failures compared with other locations or payer types. No patients returned for missed UTI/IBI. CONCLUSIONS: Concomitant bacterial infections were rare in infants with SSTI, with none identified in afebrile infants. Treatment failure of SSTI leading to hospital revisit was common.

Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes.

BACKGROUND: Cellulitis is a common infection with wide variation of clinical care. OBJECTIVE: To implement an evidence-based care pathway and evaluate changes in process metrics, clinical outcomes, and cost for cellulitis. DESIGN: A retrospective observational pre-/postintervention study was performed. SETTING: University of Utah Health Care, a 500-bed academic medical center in Salt Lake City, Utah. PATIENTS: All patients 18 years or older admitted to the emergency department observation unit or hospital with a primary diagnosis of cellulitis. INTERVENTION: Development of an evidence-based care pathway for cellulitis embedded into the electronic medical record with education for all emergency and internal medicine physicians. MEASUREMENTS: Primary outcome of broad-spectrum antibiotic use. Secondary outcomes of computed tomography/magnetic resonance imaging orders, length of stay (LOS), 30-day readmission, and pharmacy, lab, imaging, and total facility costs. RESULTS: A total of 677 visits occurred, including 370 visits where order sets were used. Among all patients, there was a 59% decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), 23% decrease in pharmacy cost (P = 0.002), and 13% decrease in total facility cost (P = 0.006). Compared to patients for whom order sets were not used, patients for whom order sets were used had a 75%, 13%, and 25% greater decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), clinical LOS (P = 0.041), and pharmacy costs (P = 0.074), respectively. CONCLUSION: The evidence-based care pathway for cellulitis improved care at an academic medical center by reducing broad-spectrum antibiotic use, pharmacy costs, and total facility costs without an adverse change in LOS or 30-day readmissions.

Outcome assessment in cellulitis clinical trials: is telephone follow up sufficient?

The US Food and Drug Administration has scrutinized clinical trial methodology in cellulitis, partly because the definition and timing of cure are debatable. We analysed the validity of telephone self-report as a proxy for in-person follow up in a cellulitis treatment trial comparing cephalexin alone with cephalexin-plus-trimethoprim/sulfamethoxazole. Our results demonstrate poor agreement between these two methods of outcome determination and have implications for future cellulitis clinical trial design and clinical management.